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Sisk BA, Harvey K, Friedrich AB, Antes AL, Yaeger LH, Mack JW, DuBois J. Multilevel barriers and facilitators of communication in pediatric oncology: A systematic review. Pediatr Blood Cancer 2022; 69:e29405. [PMID: 34662485 PMCID: PMC8875310 DOI: 10.1002/pbc.29405] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 01/03/2023]
Abstract
Multiple factors can facilitate or impede the fulfillment of communication functions in pediatric cancer. In this systematic review, we evaluated 109 studies from the preceding 20 years that presented qualitative or quantitative evidence of barriers or facilitators to communication in pediatric cancer. Using a multilevel framework developed in our prior study, we then analyzed and categorized the levels of barriers and facilitators identified in included studies. The vast majority of studies focused on individual-level barriers, rather than team, organization/system, collaborating hospital, community, or policy-level barriers. Future studies should explore the full range of factors that affect communication.
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Affiliation(s)
- Bryan A. Sisk
- Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St. Louis, Missouri.,Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Kieandra Harvey
- Brown School of Social Work, Washington University School of Medicine, St. Louis, Missouri
| | - Annie B. Friedrich
- Albert Gnaegi Center for Health Care Ethics, Saint Louis University, St. Louis, Missouri
| | - Alison L. Antes
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Lauren H Yaeger
- Bernard Becker Medical Library, Washington University School of Medicine, St. Louis, Missouri
| | - Jennifer W. Mack
- Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts; and Division of Pediatric Hematology/Oncology, Boston Children’s Hospital, Boston, Massachusetts
| | - James DuBois
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
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Aristizabal P, Ma AK, Kumar NV, Perdomo BP, Thornburg CD, Martinez ME, Nodora J. Assessment of Factors Associated With Parental Perceptions of Voluntary Decisions About Child Participation in Leukemia Clinical Trials. JAMA Netw Open 2021; 4:e219038. [PMID: 33944924 PMCID: PMC8097494 DOI: 10.1001/jamanetworkopen.2021.9038] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
IMPORTANCE Obtaining voluntary informed consent prior to enrollment in clinical trials is a fundamental ethical requirement. OBJECTIVE To assess whether health literacy, contextual factors, or sociodemographic characteristics are associated with perception of voluntariness among parents who had consented for their child's participation in a leukemia therapeutic clinical trial. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study prospectively enrolled 97 parents of children diagnosed as having leukemia at Rady Children's Hospital San Diego, a large tertiary academic center in California, from 2014 to 2017. Health literacy, contextual factors (acculturation, decisional regret, and satisfaction with informed consent), sociodemographic characteristics, and perception of voluntariness after consenting for a therapeutic clinical trial were measured. Univariable and multivariable regression were used to determine significant associations. The analyses for the present study were conducted from May 2019 to May 2020. EXPOSURES Informed consent for a therapeutic leukemia clinical trial. MAIN OUTCOMES AND MEASURES The primary outcome of interest was perception of voluntariness and its associations with health literacy and other contextual factors (acculturation, decisional regret, and satisfaction with informed consent) and sociodemographic characteristics, including age, race/ethnicity, parental language, educational level, insurance type, marital status, and socioeconomic status. RESULTS Of 97 parents included, the majority were women (65 [67%]), married (71 [73%]), and of self-reported Hispanic ethnicity (50 [52%]). Lower perception of voluntariness was significantly associated with lower health literacy (r = 0.30; 95% CI, 0.11-0.47; P = .004), Spanish language (x̅ = -4.50, P = .05), lower acculturation if of Hispanic ethnicity (r = 0.30; 95% CI, 0.02-0.54; P = .05), greater decisional regret (r = -0.54; 95% CI, -0.67 to -0.38; P < .001), and lower satisfaction with informed consent (r = 0.39; 95% CI, 0.21-0.54; P < .001) in univariable analysis. Lower health literacy remained significantly associated with lower perception of voluntariness in multivariable analysis after adjustment for contextual factors and sociodemographic characteristics (β = 4.06; 95% CI, 1.60-6.53; P = .001). Lower health literacy was significantly associated with Hispanic ethnicity (mean, 4.16; 95% CI, 3.75-4.57; P < .001), Spanish language spoken at home (mean, 3.17; 95% CI, 1.94-4.40; P < .001), high school or less educational level (mean, 3.41; 95% CI, 2.83-3.99; P < .001), public insurance (mean, 4.00; 95% CI, 3.55-4.45; P < .001), and unmarried status (mean, 3.71; 95% CI, 2.91-4.51; P = .03). CONCLUSIONS AND RELEVANCE Among parents of children with newly diagnosed leukemia who had consented for their child's participation in a therapeutic clinical trial, lower perception of voluntariness was significantly associated with lower health literacy. These results suggest that parents with low health literacy may perceive external influences in their decision for their child's participation in clinical trials. This finding highlights the potential role of recruitment interventions tailored to the participant's health literacy level to improve voluntary informed consent in underserved populations.
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Affiliation(s)
- Paula Aristizabal
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of California San Diego, La Jolla
- Peckham Center for Cancer and Blood Disorders, Rady Children’s Hospital San Diego, San Diego
- Population Sciences, Disparities and Community Engagement, University of California San Diego Moores Cancer Center, La Jolla
| | - Arissa K. Ma
- School of Medicine, University of California San Diego, La Jolla
- Now with MemorialCare Health System, Fountain Valley, California
| | - Nikhil V. Kumar
- School of Medicine, University of California San Diego, La Jolla
| | - Bianca P. Perdomo
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of California San Diego, La Jolla
- Peckham Center for Cancer and Blood Disorders, Rady Children’s Hospital San Diego, San Diego
- Population Sciences, Disparities and Community Engagement, University of California San Diego Moores Cancer Center, La Jolla
| | - Courtney D. Thornburg
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of California San Diego, La Jolla
- Peckham Center for Cancer and Blood Disorders, Rady Children’s Hospital San Diego, San Diego
| | - Maria Elena Martinez
- Population Sciences, Disparities and Community Engagement, University of California San Diego Moores Cancer Center, La Jolla
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla
| | - Jesse Nodora
- Population Sciences, Disparities and Community Engagement, University of California San Diego Moores Cancer Center, La Jolla
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla
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Winestone LE, Getz KD, Rao P, Li Y, Hall M, Huang YSV, Seif AE, Fisher BT, Aplenc R. Disparities in pediatric acute myeloid leukemia (AML) clinical trial enrollment. Leuk Lymphoma 2019; 60:2190-2198. [PMID: 30732497 PMCID: PMC6685754 DOI: 10.1080/10428194.2019.1574002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 12/22/2018] [Accepted: 01/17/2019] [Indexed: 10/27/2022]
Abstract
Equal access to clinical trial enrollment is important to ensure that findings are generalizable to the broader population. This study aimed to evaluate disparities in enrollment on pediatric oncology clinical trials. We assessed the relationship between patient characteristics and enrollment on COG trial AAML1031 in a cohort of pediatric patients with AML in the Pediatric Health Information System. The associations of enrollment with outcomes were evaluated. Non-Hispanic Black patients, infants, and patients from zip codes with a lower proportion of poverty were less likely to enroll (30% vs. 61%, p = .004; 34% vs. 58%, p = .003; 46% vs. 58%, p = .02). On-therapy mortality was similar among enrolled and nonenrolled patients (7.3% vs. 8.9%, p = .47). Differences in early mortality were more pronounced among nonenrolled patients compared to enrolled patients (3.0% vs. 0.5%, p = .03). Understanding the etiology of these disparities will inform strategies to ensure balanced access to clinical trials across patient populations.
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Affiliation(s)
- Lena E. Winestone
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
- Division of AIBMT, Department of Pediatrics, University of California – San Francisco (UCSF) Benioff Children’s Hospital, San Francisco, CA, USA
| | - Kelly D. Getz
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Pooja Rao
- Division of Pediatric Hematology/Oncology, Penn State Children’s Hospital, Hershey, PA, USA
| | - Yimei Li
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Matt Hall
- Children’s Hospital Association, Lenexa, KS, USA
| | - Yuan-Shung V. Huang
- Healthcare Analytics Unit, Department of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alix E. Seif
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Brian T. Fisher
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Infectious Diseases, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Richard Aplenc
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Do parents of children with cancer want to participate in treatment decision-making? Support Care Cancer 2019; 28:1059-1067. [PMID: 31177389 DOI: 10.1007/s00520-019-04909-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 04/14/2019] [Accepted: 05/31/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE This study aimed to describe parents' preferences regarding their role in treatment decision-making when a child has cancer and examines whether their preferences were related to parents sociodemographic characteristics (sex and education level), patients' characteristics (age group and treatment status), and healthcare context features (parents' perception of family-centered care). METHODS Two hundred and twenty-eight parents of children/adolescents with cancer were recruited from two Portuguese pediatric oncology wards. Participants provided sociodemographic and clinical information. The Control Preferences Scale for Pediatrics was used to assess the parents' preferred role in treatment decision-making. The Measure of Process of Care assessed the parents' perception of family-centered care (family-centered services and providing general information subscales). RESULTS Results showed that parents preferred a passive-collaborative role (45.2%), followed by collaborative (27.2%), passive (21.0%), and active-collaborative (6.6%). None preferred an active role. Chi-square test showed that the group of parents preferring a passive role had a lower proportion of more-educated parents, compared to those preferring active-collaborative or collaborative roles. Additionally, groups did not proportionally differ according to the parents' sex, patients' age, and treatment status. A multivariate analysis of variance showed that parents preferring an active-collaborative role reported lower mean scores on family-centered services compared to those preferring passive-collaborative and passive roles. Finally, no significant differences were found concerning providing general information. CONCLUSIONS This study's findings may guide professionals in identifying parents' preferences regarding their participation in treatment decision-making process. Mapping their preferences may support professionals in promoting desirable levels of parental involvement in decisions in pediatric oncology context.
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Stegenga K, Pentz RD, Alderfer MA, Pelletier W, Fairclough D, Hinds PS. Child and Parent Access to Transplant Information and Involvement in Treatment Decision Making. West J Nurs Res 2018; 41:576-591. [PMID: 29644930 DOI: 10.1177/0193945918770440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Pediatric stem cell transplant processes require information sharing among the patient, family, and clinicians regarding the child's condition, prognosis, and transplant procedures. To learn about perceived access to transplant information and involvement in decision making among child family members (9-22 years old), we completed a secondary analysis of 119 interviews conducted with pediatric patients, sibling donors, nondonor siblings/cousins, and guardians from 27 families prior to transplant. Perceptions of information access and involvement in transplant-related decisions were extracted and summarized. We compared child member perceptions to their guardians' and examined differences by child age and gender. Most child members perceived exclusion from transplant (79%) and donor (63%) information and decisions (63%) although this varied by child role. Gender was unrelated to involvement; older age was associated with less perceived exclusion. Congruence in perspectives across children and guardians was evident for eight (30%) families, most of whom ( n = 7) excluded the children.
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Affiliation(s)
| | | | - Melissa A Alderfer
- 3 Thomas Jefferson University, Philadelphia, PA, USA.,4 Nemours Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | | | | | - Pamela S Hinds
- 7 Children's National Health System, Washington, DC, USA.,8 The George Washington University, Washington, DC, USA
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Tom DM, Aquino C, Arredondo AR, Foster BA. Parent Preferences for Shared Decision-making in Acute Versus Chronic Illness. Hosp Pediatr 2017; 7:602-609. [PMID: 28951430 PMCID: PMC5613816 DOI: 10.1542/hpeds.2017-0049] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The goal of this study was to examine preferences for shared decision-making (SDM) in parents of acutely ill versus chronically ill children in the inpatient setting. Additionally, we explored the effect of parental perception of illness severity and uncertainty in illness on decision-making preference. METHODS In this cross-sectional study, we surveyed parents of children admitted to pediatric inpatient units at an academic, tertiary-care hospital. Surveys were administered in person and used validated tools to assess SDM preferences and uncertainty in illness. Descriptive statistics evaluated associations stratified by acute versus chronic illness, and multivariable analyses were performed. RESULTS Of the 200 parents who participated, the majority were women (78%), Hispanic (81.5%), English speaking (73%), between 30 and 39 years old (37.5%), and had an education achievement of less than a college degree (77%). The mean age of hospitalized children was 8.1 years, and half reported a chronic illness. Most parents preferred an active (43%) or collaborative (40%) role in SDM. There was no association with SDM preference by demographics, number of previous hospitalizations, perception of illness severity, or uncertainty. However, parents of chronically ill children significantly preferred a passive role in SDM when they perceived a high level of uncertainty in illness. CONCLUSIONS Most parents of hospitalized children prefer to take an active or collaborative role in SDM. However, parents of chronically ill children who perceive high levels of uncertainty surrounding their children's illness prefer a passive role, thus illustrating the complexity in decision-making among this parent population.
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Affiliation(s)
- Dina M Tom
- Division of Inpatient Pediatrics, Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Texas; and
- University Hospital, San Antonio, Texas
| | - Christian Aquino
- Division of Inpatient Pediatrics, Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Texas; and
- University Hospital, San Antonio, Texas
| | - Anthony R Arredondo
- Division of Inpatient Pediatrics, Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Texas; and
- University Hospital, San Antonio, Texas
| | - Byron A Foster
- Division of Inpatient Pediatrics, Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Texas; and
- University Hospital, San Antonio, Texas
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Shader RI, Livingston CH. Informed Consent and Assent in Pediatric Oncology Trials. Clin Ther 2017; 39:231-234. [DOI: 10.1016/j.clinthera.2017.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 01/13/2017] [Indexed: 10/20/2022]
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Day E, Jones L, Langner R, Bluebond-Langner M. Current understanding of decision-making in adolescents with cancer: A narrative systematic review. Palliat Med 2016; 30:920-934. [PMID: 27160700 PMCID: PMC5117127 DOI: 10.1177/0269216316648072] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Policy guidance and bioethical literature urge the involvement of adolescents in decisions about their healthcare. It is uncertain how roles and expectations of adolescents, parents and healthcare professionals influence decision-making and to what extent this is considered in guidance. AIMS To identify recent empirical research on decision-making regarding care and treatment in adolescent cancer: (1) to synthesise evidence to define the role of adolescents, parents and healthcare professionals in the decision-making process and (2) to identify gaps in research. DESIGN A narrative systematic review of qualitative, quantitative and mixed-methods research. We adopted a textual approach to synthesis, using a theoretical framework of interactionism to interpret findings. DATA SOURCES The databases MEDLINE, PsycINFO, SCOPUS, EMBASE and CINHAL were searched from 2001 through May 2015 for publications on decision-making for adolescents (13-19 years) with cancer. RESULTS Twenty-eight articles were identified. Adolescents and parents initially find it difficult to participate in decision-making due to a lack of options in the face of protocol-driven care. Parent and adolescent preferences for information and response to loss of control vary between individuals and over time. No studies indicate parental or adolescent preference for a high degree of independence in decision-making. CONCLUSION Striving to make parents and adolescents fully informed or urge them towards more independence than they prefer may add to distress and confusion. This may interfere with their ability to participate in their preferred way in decisions about care and treatment. Future research should include analysis of on-ground interactions among parents, adolescents and clinicians across the trajectory.
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Affiliation(s)
- Emma Day
- Louis Dundas Centre for Children's Palliative Care, Institute of Child Health, University College London (UCL), London, UK
| | - Louise Jones
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London (UCL), London, UK
| | - Richard Langner
- Louis Dundas Centre for Children's Palliative Care, Institute of Child Health, University College London (UCL), London, UK
| | - Myra Bluebond-Langner
- Louis Dundas Centre for Children's Palliative Care, Institute of Child Health, University College London (UCL), London, UK
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Ethical issues of clinical trials in paediatric oncology from 2003 to 2013: a systematic review. Lancet Oncol 2016; 17:e187-97. [DOI: 10.1016/s1470-2045(16)00142-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 01/05/2016] [Accepted: 02/18/2016] [Indexed: 11/20/2022]
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Mamotte N, Wassenaar D. Voluntariness of consent to HIV clinical research: A conceptual and empirical pilot study. J Health Psychol 2016; 22:1387-1404. [PMID: 26929170 DOI: 10.1177/1359105316628737] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Obtaining voluntary informed consent for research participation is an ethical imperative, yet there appears to be little consensus regarding what constitutes a voluntary consent decision. An instrument to assess influences on participants' consent decision and perceived voluntariness was developed and piloted in two South African HIV clinical trials. The pilot study found high levels of perceived voluntariness. The feeling of having no choice but to participate was significantly associated with lower perceived voluntariness. Overall the data suggest that it is possible to obtain voluntary and valid consent for research participants in ethically complex HIV clinical trials in a developing country context.
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Affiliation(s)
- Nicole Mamotte
- School of Applied Human Sciences, University of KwaZulu-Natal, South Africa
| | - Douglas Wassenaar
- School of Applied Human Sciences, University of KwaZulu-Natal, South Africa
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Chiu HH, Dimaras H, Downie R, Gallie B. Breaking down barriers to communicating complex retinoblastoma information: can graphics be the solution? Can J Ophthalmol 2016; 50:230-5. [PMID: 26040224 DOI: 10.1016/j.jcjo.2015.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Revised: 12/08/2014] [Accepted: 02/01/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To investigate the impact of a graphical timeline summarizing bilateral retinoblastoma disease and treatment outcomes on parents' understanding of complex medical information. DESIGN Cross-sectional survey. PARTICIPANTS Parents of children with retinoblastoma who were being actively managed at The Hospital for Sick Children were recruited. Forty-five parents from 42 families participated. METHODS After a standardized presentation on retinoblastoma and visual tool named Disease-Specific electronic Patient Illustrated Clinical Timeline (DePICT), parents completed a 19-item questionnaire designed to assess their understanding of treatment choices for 2 eyes in bilateral retinoblastoma as communicated using DePICT. SPSS was used to perform statistical analysis. RESULTS Forty-five parents from 42 families participated (65% female). Median age of participants was 34 years. Median level of participant education was completion of college/trade school. The median level of annual income was $40,000 to $70,000 CDN. Median time since diagnosis of retinoblastoma in their child was 13.5 months. Twenty-three (51%) participants were parents of children with unilateral retinoblastoma, and 22 (49%) were parents of children with bilateral retinoblastoma. Median number of correct answers was 15 of 19, and mean score was 77%. Normal distribution of scores was noted. English as a first language was significantly associated with score (p = 0.01). No significant association was observed between other variables and score in all analyses. CONCLUSIONS This study builds on the validation of DePICT by demonstrating that parents can achieve good comprehension even when considering choices for treatment for 2 eyes with bilateral retinoblastoma. Clinical application of this tool can enhance the consent process.
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Affiliation(s)
- Hannah H Chiu
- Department of Ophthalmology and Vision Sciences, Faculty of Medicine, University of Toronto
| | - Helen Dimaras
- Department of Ophthalmology and Vision Sciences, Faculty of Medicine, University of Toronto; Division of Hematology/Oncology, The Hospital for Sick Children, Toronto
| | - Rob Downie
- Research, Policy and Planning, Fanshawe College, London
| | - Brenda Gallie
- Department of Ophthalmology and Vision Sciences, Faculty of Medicine, University of Toronto; Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children; Ontario Cancer Institute, Princess Margaret Hospital, Toronto, Ont..
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Abstract
BACKGROUND In pediatric oncology, many oncologists invite their own patients to participate in research. Inclusion within a dependent relationship is considered to potentially compromise voluntariness of consent. Currently, it is unknown to what extent those involved in pediatric oncology experience the dependent relationship as a threat to voluntary informed consent, and what they see as safeguards to protect voluntary informed consent within a dependent relationship. AIM We performed a qualitative study among key actors in pediatric oncology to explore their experiences with the dependent relationship and voluntary informed consent. METHODS We conducted three focus groups and 25 semi-structured, in-depth interviews with pediatric oncologists, research coordinators, Research Ethics Committee members, parents of children with cancer, and adolescents with cancer. RESULTS Professionals regarded the dependent relationship both as a potential threat to and as a positive influence on voluntary decision making. Parents and adolescents did not feel as though dependency upon the oncologist influenced their decisions. They valued the involvement of their own physician in the informed consent process. The professionals suggested three strategies to protect voluntariness: emphasizing voluntariness; empowering families; involvement of an independent person. CONCLUSIONS Although the dependent relationship between pediatric oncologists, patients and parents may be problematic for voluntary informed consent, this is not necessarily the case. Moreover, the involvement of treating physicians may even have a positive impact on the informed consent process. Although we studied pediatric oncology, our results may also apply to many other fields of pediatric medicine where research and care are combined, for example, pediatric rheumatology, neurology and nephrology. Clinical trials in these fields are inevitably often designed, initiated and conducted by medical specialists closely involved in patient care.
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Bloomfield FH. The challenges of research participation by children. Pediatr Res 2015; 78:109-10. [PMID: 25923012 DOI: 10.1038/pr.2015.75] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 03/26/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Frank H Bloomfield
- 1] Liggins Institute, University of Auckland, Auckland, New Zealand [2] Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand [3] Newborn Services, National Women's Health, Auckland City Hospital, Auckland, New Zealand [4] Gravida: National Centre for Growth and Development, Auckland, New Zealand
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Scollon S, Bergstrom K, Kerstein RA, Wang T, Hilsenbeck SG, Ramamurthy U, Gibbs RA, Eng CM, Chintagumpala MM, Berg SL, McCullough LB, McGuire AL, Plon SE, Parsons DW. Obtaining informed consent for clinical tumor and germline exome sequencing of newly diagnosed childhood cancer patients. Genome Med 2014; 6:69. [PMID: 25317207 PMCID: PMC4195891 DOI: 10.1186/s13073-014-0069-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 09/02/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Effectively educating families about the risks and benefits of genomic tests such as whole exome sequencing (WES) offers numerous challenges, including the complexity of test results and potential loss of privacy. Research on best practices for obtaining informed consent (IC) in a variety of clinical settings is needed. The BASIC3 study of clinical tumor and germline WES in an ethnically diverse cohort of newly diagnosed pediatric cancer patients offers the opportunity to study the IC process in the setting of critical illness. We report on our experience for the first 100 families enrolled, including study participation rates, reasons for declining enrollment, assessment of clinical and demographic factors that might impact study enrollment, and preferences of parents for participation in optional genomics study procedures. METHODS A specifically trained IC team offered study enrollment to parents of eligible children for procedures including clinical tumor and germline WES with results deposited in the medical record and disclosure of both diagnostic and incidental results to the family. Optional study procedures were also offered, such as receiving recessive carrier status and deposition of data into research databases. Stated reasons for declining participation were recorded. Clinical and demographic data were collected and comparisons made between enrolled and non-enrolled patients. RESULTS Over 15 months, 100 of 121 (83%) eligible families elected to enroll in the study. No significant differences in enrollment were detected based on factors such as race, ethnicity, use of Spanish interpreters and Spanish consent forms, and tumor features (central nervous system versus non-central nervous system, availability of tumor for WES). The most common reason provided for declining enrollment (10% of families) was being overwhelmed by the new cancer diagnosis. Risks specific to clinical genomics, such as privacy concerns, were less commonly reported (5.5%). More than 85% of parents consented to each of the optional study procedures. CONCLUSIONS An IC process was developed that utilizes a specialized IC team, active communication with the oncology team, and an emphasis on scheduling flexibility. Most parents were willing to participate in a clinical germline and tumor WES study as well as optional procedures such as genomic data sharing independent of race, ethnicity or language spoken.
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Affiliation(s)
- Sarah Scollon
- Texas Children's Cancer Center, 6701 Fannin Street #1400, Houston, TX 77030 USA ; Department of Pediatrics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA
| | - Katie Bergstrom
- Texas Children's Cancer Center, 6701 Fannin Street #1400, Houston, TX 77030 USA ; Department of Pediatrics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA
| | - Robin A Kerstein
- Texas Children's Cancer Center, 6701 Fannin Street #1400, Houston, TX 77030 USA ; Department of Pediatrics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA
| | - Tao Wang
- Dan L. Duncan Cancer Center, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA
| | - Susan G Hilsenbeck
- Dan L. Duncan Cancer Center, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA
| | - Uma Ramamurthy
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA
| | - Richard A Gibbs
- Human Genome Sequencing Center, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA ; Department of Molecular and Human Genetics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA
| | - Christine M Eng
- Department of Molecular and Human Genetics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA
| | - Murali M Chintagumpala
- Texas Children's Cancer Center, 6701 Fannin Street #1400, Houston, TX 77030 USA ; Department of Pediatrics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA ; Dan L. Duncan Cancer Center, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA
| | - Stacey L Berg
- Texas Children's Cancer Center, 6701 Fannin Street #1400, Houston, TX 77030 USA ; Department of Pediatrics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA ; Dan L. Duncan Cancer Center, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA
| | - Laurence B McCullough
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA
| | - Amy L McGuire
- Dan L. Duncan Cancer Center, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA ; Human Genome Sequencing Center, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA ; Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA
| | - Sharon E Plon
- Texas Children's Cancer Center, 6701 Fannin Street #1400, Houston, TX 77030 USA ; Department of Pediatrics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA ; Dan L. Duncan Cancer Center, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA ; Human Genome Sequencing Center, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA ; Department of Molecular and Human Genetics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA
| | - D Williams Parsons
- Texas Children's Cancer Center, 6701 Fannin Street #1400, Houston, TX 77030 USA ; Department of Pediatrics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA ; Dan L. Duncan Cancer Center, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA ; Human Genome Sequencing Center, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA ; Department of Molecular and Human Genetics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA
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15
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Dekking SAS, van der Graaf R, van Delden JJM. Strengths and weaknesses of guideline approaches to safeguard voluntary informed consent of patients within a dependent relationship. BMC Med 2014; 12:52. [PMID: 24655604 PMCID: PMC3998040 DOI: 10.1186/1741-7015-12-52] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 02/24/2014] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND It is thought that a dependent relationship between patients and physicians who enroll their own patients in research compromises voluntary informed consent. Therefore, several ethical guidelines for human subject research provide approaches to mitigate these compromises. Currently, these approaches have not been critically evaluated. In this article, we analyze the approaches of ethical guidelines to manage the influence of a dependent relationship between patients and physicians on voluntary informed consent and discuss the strengths and weaknesses of these approaches. METHODS We performed a review of international ethical guidance documents on human subject research, listed in the Oxford Textbook of Clinical Research Ethics and found through cross referencing. We also searched Global Ethics Observatory (GEObs) and the World Health Organization (WHO) website. Guidelines from all years were eligible for inclusion. The date last searched was December 2013. DISCUSSION We identified two basic guideline approaches: 1. A process approach, which focuses on the person who obtains informed consent, that is, an independent individual, such as a research nurse or counselor; and 2. A content approach, emphasizing the voluntary nature of participation. Both approaches are valuable, either because the influence of the physician may diminish or because it empowers patients to make voluntary decisions. However, the approaches also face challenges. First, research nurses are not always independent. Second, physician-investigators will be informed about decisions of their patients. Third, involvement of a counselor is sometimes unfeasible. Fourth, the right to withdraw may be difficult to act upon in a dependent relationship. CONCLUSIONS Current guideline approaches to protect voluntary informed consent within a dependent relationship are suboptimal. To prevent compromises to voluntary informed consent, consent should not only be obtained by an independent individual, but this person should also emphasize the voluntary nature of participation. At the same time, dependency as such does not imply undue influence. Sometimes the physician may be best qualified to provide information, for example, for a very specialized study. Still, the research nurse should obtain informed consent. In addition, patients should be able to consult a counselor, who attends the informed consent discussions and is concerned with their interests. Finally, both physicians and research nurses should disclose research interests.
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Affiliation(s)
- Sara A S Dekking
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
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16
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Slone JS, Self E, Friedman D, Heiman H. Disparities in pediatric oncology patient education and linguistic resources: results of a national survey of pediatric oncologists. Pediatr Blood Cancer 2014; 61:333-6. [PMID: 24167088 PMCID: PMC3877218 DOI: 10.1002/pbc.24831] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 09/26/2013] [Indexed: 11/10/2022]
Abstract
BACKGROUND Extensive patient and family education is required at the time of a new diagnosis of pediatric cancer yet little data exist regarding the availability and linguistic competency of new cancer diagnosis education provided by pediatric oncology institutions. PROCEDURE Using the American Society of Pediatric Hematology/Oncology (ASPHO) membership list, a web-based survey was conducted among a cohort of pediatric oncologists to determine pediatric oncologists' assessment of institutional resources for new cancer diagnosis education and the availability of linguistically appropriate education. RESULTS Of 1,294 ASPHO members sent email survey invitations, 573 (44.3%) responded with 429 meeting eligibility criteria. Oncologists at academic institutions reported their institutions had more availability of resources for new diagnosis education compared with those from non-academic institutions (mean 78.6 vs. 74.3; 0 [not at all]-100 [well equipped]; P = 0.05). The mean score increased with volume of new cancer diagnoses/year: small (<75) = 73.4; medium (75-149) = 76.7; large (>150) = 84.5 (P < 0.001). Oncologists at large volume institutions reported more availability of an established patient education protocol (50.8% vs. 38.1%, P < 0.001) and increased use of dedicated non-physician staff (79.9% vs. 66.1%, P = 0.02), but less use of websites for patient education (17.2% vs. 33.3%, P = 0.001). Availability of linguistically appropriate education improved with increasing institution size: small (76.4), medium (82.3), and large (84.0) patient volume (P < 0.011). CONCLUSION According to pediatric oncologists, a disparity in educational and linguistic resources for new pediatric cancer diagnosis education exists depending on institution type and size.
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Affiliation(s)
- Jeremy S Slone
- Division of Pediatric Hematology-Oncology, Vanderbilt University
| | | | - Debra Friedman
- Division of Pediatric Hematology-Oncology, Vanderbilt University
| | - Harry Heiman
- Satcher Health Leadership Institute, Morehouse School of Medicine
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17
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Roth-Cline M, Nelson RM. Parental permission and child assent in research on children. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2013; 86:291-301. [PMID: 24058304 PMCID: PMC3767214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Grounded on the ethical principle of respect for persons, parental permission and child assent function together to protect the child and to foster the development of the child's self-determination. Although both parental permission and child assent involve the same components of information sharing, comprehension, and voluntariness, how these three components are understood and operationalized should differ depending on the developmental level of the child. For example, the amount of information that a child must comprehend to provide meaningful and developmentally appropriate child assent (or dissent) should be allowed to vary with the age and maturity of the child. By understanding child assent together with the important protections of parental permission, child assent does not need to be burdened with the same informational and process requirements. As a result, the age (as a proxy for developmental stage) at which a child is deemed capable of assent would be lower (i.e., 5 to 7 years old). By assuming a lack of capacity, the potential arises to dishonor and disregard a child's wishes by failing to solicit meaningful assent or dissent. Further research needs to be done on how best to obtain truly informed and voluntary parental permission and child assent for research participation.
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Affiliation(s)
- Michelle Roth-Cline
- Office of Pediatric Therapeutics, Food and Drug Administration, Silver Spring,
Maryland
| | - Robert M. Nelson
- Office of Pediatric Therapeutics, Food and Drug Administration, Silver Spring,
Maryland
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